In regards to ICD-10 readiness, the good news is that 85 percent of organizations have begun either ICD-10 transition planning or implementation. This is up from 62 percent a year ago, per an August 2011 survey by the American Health Information Management Association. The bad news is that ICD-10 readiness assessments conducted at these sites uncovered a very large scope of work ahead. There is much to be accomplished before the Oct. 1, 2013, deadline.
Countries that have already been using ICD-10 for nearly a decade have reported the transition to ICD-10 took longer and cost more than anyone had anticipated. However, since these countries do not use ICD-10 for reimbursement purposes, our transition will be even more complex.
ICD-10 requires a team effort
When it comes to ICD-10, a team effort is required. Collaboration between internal, multi-disciplinary groups and outside vendors is almost always necessary to ease the logistics and transition. Once organizations peel back the layers of the ICD-10 onion, the project's complexities and intricacies rapidly appear.
One area ripe for outside support is the initial gap analysis and business process re-engineering. Organizations should develop a framework for the type of assistance that will be needed, establish a checklist of requirements and thoroughly evaluate vendors.
Technology readiness assessment and vendor coordination
First, a detailed technical analysis must be performed and include an assessment of all systems that house a three to five digit ICD-9 code. Organizations must work with existing and prospective system providers to determine what software and hardware changes are needed to accommodate a 7-digit, alpha-numeric code. Evaluations will determine if systems are compliant, a software upgrade is needed or an entirely new application will be required.
Creating the system matrix, negotiating with vendors and implementing new software versions is an extensive project. Outside healthcare information technology consultants may be better positioned to complete this work than already over-tasked internal staff.
According to AHIMA's ICD-10-CM/PCS Transition: Planning and Preparation Checklist, technology readiness assessments are part of phase-one preparations and should have been conducted by July 2011. See below for a list of systems that must be reviewed.
• ADT and financial systems
• Billing systems
• Decision support systems
• Clinical systems
• Encoding software
• Health record abstracting systems
• Aggregate data reporting
• Utilization and quality management systems
• Case-mix systems
• Performance measurement systems
• Medical necessity software
• Benefits determination software
• System interfaces
Additionally, the health system should ask the following questions of its technology vendors:
• Can the system accommodate a 7-digit, alpha-numeric code?
• If not, when will new software (and hardware if necessary) be available for testing, for live production?
• When will interfaces between this system and others be ready?
• Will there be a cost for the upgrade? If so, what is the cost?
• Will an entirely new system be required?
• Will the ICD-10 version require additional support fees?
• Will the software use GEMS mapping and if so, for how long?
Exploring the impact on clinicians, operations and revenue cycle
On the clinical and operations front, much needs to be accomplished to accommodate the increased granularity of information needed for ICD-10 coding. The focus here must be on assessing and improving clinical documentation. The clinical documentation aspect is an additional recommended area for outside, expert resources. Ideally, the firm should include physicians with coding and documentation expertise for peer-to-peer presentations and training.
Incomplete or insufficient documentation leads to under-coding and less than optimal reimbursement. The negative cause-and-effect relationship between documentation and coding worsens under ICD-10. Non-specific codes and catch-all MS-DRGs result in potentially lower reimbursement for hospitals and poor quality scores for physicians.
HIM coding experts are able to analyze current documentation and ICD-9 coding, and forecast how ICD-10 will have an impact on revenue. This analysis answers critical questions such as which MS-DRGs are at greatest risk for reduced reimbursement, which physicians will produce lower quality scores and what organizations must forecast and budget for the reimbursement impact of the change. Armed with this knowledge, hospital executives and medical staff directors can then work together with physicians to identify documentation weaknesses and implement remediation plans.
Contract now for coder assessments, training and back-up support
As for coder assessments and training, most organizations recognize the need for an outside vendor, but not due to a lack of qualified internal staff that could perform the training. Instead, organizations are realizing that it is more important to keep existing coders focused on day-to-day production, revenue-cycle activities and mastering the new coding system. The everyday, full-time demands preclude in-house coders from training their peers.
For most organizations, coder assessments and training will be outsourced. Existing vendor relationships and long-term partners may offer a solution. However, several qualifying criteria should be used for evaluating outside training vendors. The company should:
• Have its roots in the HIM/coding arena.
• Be willing to contract now.
• Include coder assessments as well as anatomy and physiology training as the first step.
• Have a long history of high-quality coding and evidence of their ICD-10 expertise.
• Offer back-up, interim coding services during the training period.
Tips for ICD-10 partnerships
When choosing a vendor, there are two lessons to share. One is ensure your organization understands the budget implications for all of the outsourced services needed for ICD-10. A multi-year budget plan should be put into place including operational (training, outsourcing, hiring, etc.) and capital costs (upgrading and replacing software). The transition process will cost more than expected, so budget for contingency issues and the inevitable unknown 'gotcha'.
Obviously, finding a vendor with a long history or rich experience in ICD-10 can be difficult since no organization in the U.S. has transitioned to ICD-10. The best alternative is to select vendors steeped in the areas most directly impacted by ICD-10. They should have performed similar work with same-sized organizations and clear the reference call hurdle. Executives and ICD-10 team members are encouraged to communicate with peers and ask about outside resources through 'word of mouth' in the HIM industry.
Ms. Felix's 20 years of coding experience includes lead coder at the University of Pennsylvania Health System, auditor for Aspen Systems Consulting and manager of coding operations for Universal Health Services. Her education experience includes adjunct faculty at Gwynedd-Mercy College and study mentor for the Health Informatics Program at Western Governors University. She wrote the lesson plan book for Elsevier’s ICD-9-CM Coding Theory and Practice Textbook and has also developed questions for a web-based CCS Exam review for Northstar Learning. She has developed a CCS Prepatory Workshop that has been touring the state of Pennsylvania.
Countries that have already been using ICD-10 for nearly a decade have reported the transition to ICD-10 took longer and cost more than anyone had anticipated. However, since these countries do not use ICD-10 for reimbursement purposes, our transition will be even more complex.
ICD-10 requires a team effort
When it comes to ICD-10, a team effort is required. Collaboration between internal, multi-disciplinary groups and outside vendors is almost always necessary to ease the logistics and transition. Once organizations peel back the layers of the ICD-10 onion, the project's complexities and intricacies rapidly appear.
One area ripe for outside support is the initial gap analysis and business process re-engineering. Organizations should develop a framework for the type of assistance that will be needed, establish a checklist of requirements and thoroughly evaluate vendors.
Technology readiness assessment and vendor coordination
First, a detailed technical analysis must be performed and include an assessment of all systems that house a three to five digit ICD-9 code. Organizations must work with existing and prospective system providers to determine what software and hardware changes are needed to accommodate a 7-digit, alpha-numeric code. Evaluations will determine if systems are compliant, a software upgrade is needed or an entirely new application will be required.
Creating the system matrix, negotiating with vendors and implementing new software versions is an extensive project. Outside healthcare information technology consultants may be better positioned to complete this work than already over-tasked internal staff.
According to AHIMA's ICD-10-CM/PCS Transition: Planning and Preparation Checklist, technology readiness assessments are part of phase-one preparations and should have been conducted by July 2011. See below for a list of systems that must be reviewed.
• ADT and financial systems
• Billing systems
• Decision support systems
• Clinical systems
• Encoding software
• Health record abstracting systems
• Aggregate data reporting
• Utilization and quality management systems
• Case-mix systems
• Performance measurement systems
• Medical necessity software
• Benefits determination software
• System interfaces
Additionally, the health system should ask the following questions of its technology vendors:
• Can the system accommodate a 7-digit, alpha-numeric code?
• If not, when will new software (and hardware if necessary) be available for testing, for live production?
• When will interfaces between this system and others be ready?
• Will there be a cost for the upgrade? If so, what is the cost?
• Will an entirely new system be required?
• Will the ICD-10 version require additional support fees?
• Will the software use GEMS mapping and if so, for how long?
Exploring the impact on clinicians, operations and revenue cycle
On the clinical and operations front, much needs to be accomplished to accommodate the increased granularity of information needed for ICD-10 coding. The focus here must be on assessing and improving clinical documentation. The clinical documentation aspect is an additional recommended area for outside, expert resources. Ideally, the firm should include physicians with coding and documentation expertise for peer-to-peer presentations and training.
Incomplete or insufficient documentation leads to under-coding and less than optimal reimbursement. The negative cause-and-effect relationship between documentation and coding worsens under ICD-10. Non-specific codes and catch-all MS-DRGs result in potentially lower reimbursement for hospitals and poor quality scores for physicians.
HIM coding experts are able to analyze current documentation and ICD-9 coding, and forecast how ICD-10 will have an impact on revenue. This analysis answers critical questions such as which MS-DRGs are at greatest risk for reduced reimbursement, which physicians will produce lower quality scores and what organizations must forecast and budget for the reimbursement impact of the change. Armed with this knowledge, hospital executives and medical staff directors can then work together with physicians to identify documentation weaknesses and implement remediation plans.
Contract now for coder assessments, training and back-up support
As for coder assessments and training, most organizations recognize the need for an outside vendor, but not due to a lack of qualified internal staff that could perform the training. Instead, organizations are realizing that it is more important to keep existing coders focused on day-to-day production, revenue-cycle activities and mastering the new coding system. The everyday, full-time demands preclude in-house coders from training their peers.
For most organizations, coder assessments and training will be outsourced. Existing vendor relationships and long-term partners may offer a solution. However, several qualifying criteria should be used for evaluating outside training vendors. The company should:
• Have its roots in the HIM/coding arena.
• Be willing to contract now.
• Include coder assessments as well as anatomy and physiology training as the first step.
• Have a long history of high-quality coding and evidence of their ICD-10 expertise.
• Offer back-up, interim coding services during the training period.
Tips for ICD-10 partnerships
When choosing a vendor, there are two lessons to share. One is ensure your organization understands the budget implications for all of the outsourced services needed for ICD-10. A multi-year budget plan should be put into place including operational (training, outsourcing, hiring, etc.) and capital costs (upgrading and replacing software). The transition process will cost more than expected, so budget for contingency issues and the inevitable unknown 'gotcha'.
Obviously, finding a vendor with a long history or rich experience in ICD-10 can be difficult since no organization in the U.S. has transitioned to ICD-10. The best alternative is to select vendors steeped in the areas most directly impacted by ICD-10. They should have performed similar work with same-sized organizations and clear the reference call hurdle. Executives and ICD-10 team members are encouraged to communicate with peers and ask about outside resources through 'word of mouth' in the HIM industry.
Ms. Felix's 20 years of coding experience includes lead coder at the University of Pennsylvania Health System, auditor for Aspen Systems Consulting and manager of coding operations for Universal Health Services. Her education experience includes adjunct faculty at Gwynedd-Mercy College and study mentor for the Health Informatics Program at Western Governors University. She wrote the lesson plan book for Elsevier’s ICD-9-CM Coding Theory and Practice Textbook and has also developed questions for a web-based CCS Exam review for Northstar Learning. She has developed a CCS Prepatory Workshop that has been touring the state of Pennsylvania.